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What would happen to your family if you were to need nursing home care?  With Long Term Care insurance you (or your parents) won't have to worry about paying for extended care.  Get FREE no obligation Long Term Care Insurance Quotes! You could save substantially for two minutes of your time.

The short form below should be filled out as completely as possible in order to receive accurate insurance quotes.

First Name

Last Name


Street Address




Zip Code

Day Phone


Evening Phone


E-mail Address

Best time to call:

Who is this quote for?


Birthday (mm/dd/yy)



feet inches



Name of parent (if different)
(otherwise, leave blank)

Are you married?

Yes     No 

Do you smoke?

Yes     No 

Are you diabetic?

Yes     No 

Are you insulin-dependent?

Yes    No 

Do you use:

  wheel chair

If you use other medical
equipment, please describe
(otherwise, leave blank)


If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)


In the past 5 years, have you:

  been confined to a hospital/nursing home
  had home care
  had long term care
 received rehabilitation

If you have any particular health problems, please describe
(otherwise, leave blank)


Would you like an additional quote?

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